Pharmacy

Pharmacy Benefit Management (PBM) offers acute and chronic medicine management for Medimed.

ACUTE MEDICATION:

Acute medication covered may include medicine prescribed by and/or dispensed from a General Practitioner (GP), or authorised prescriber.

Acute medication, in accordance with your Scheme option, may be funded from the Acute Medication Benefit, Savings Account and/or Elective Benefit, which may be subject to applied limits, levies, and Formulary/Reference pricing or exclusions that may be applicable.

Members are encouraged to make use of Designated Service Provider (DSP) Pharmacies and representative formulary medicine, where applicable, when claiming medicine; so that member out-of-pocket expenses may be avoided.

Quantity limitations are applied to certain medicines, categorised by drug category and dosage form. However, quantity limitations do not apply to medicine authorised as chronic medication.

CHRONIC MEDICATION BENEFIT:

Chronic medication covered may include medicine prescribed by and/or dispensed from a General Practitioner (GP), or authorised prescriber.

Certain chronic medication, used to treat a specified list of chronic conditions, in accordance with your Scheme option, may be funded from the Chronic Medication Benefit.  These conditions have been selected according to clinical and actuarial criteria.

The Chronic Medication Benefit may be subject to applied limits, levies, and Formulary / Reference pricing or exclusions that may be applicable.

Members are encouraged to make use of Designated Service Provider (DSP) Pharmacies and representative formulary medicine, where applicable, when claiming medicine; so that member out-of-pocket expenses may be avoided.

Chronic Condition Coverage:

• • Chronic Disease List-The Prescribed Minimum Benefit regulations require that Medical Schemes cover the diagnosis, medical management and medicine for a specified list of 27 chronic conditions known as the Chronic Disease List (CDL). All such ailments meeting approval criteria will be authorised under the Prescribed Minimum Benefit (PMB) Medication benefit.
  • 27 CDL conditions:
    1. Addison’s Disease
    2. Asthma
    3. Bipolar Mood Disorder
    4. Bronchiectasis
    5. Cardiac Failure
    6. Cardiomyopathy
    7. Chronic Obstructive Pulmonary Disease
    8. Chronic Renal Failure
    9. Coronary Artery Disease
    10. Crohn’s Disease
    11. Diabetes Insipidus
    12. Diabetes Mellitus Type I
    13. Diabetes Mellitus Type II
    14. Dysrhythmias
    15. Epilepsy
    16. Glaucoma
    17. Haemophilia
    18. Hyperlipidaemia
    19. Hypertension
    20. Hypothyroidism
    21. Ischaemic heart disease (Including AP)
    22. Multiple Sclerosis
    23. Parkinson’s Disease
    24. Rheumatoid Arthritis
    25. Schizophrenia
    26. Systemic Lupus Erythematosus
    27. Ulcerative Colitis

• Additional Chronic Disease List- Certain medical scheme options provide cover for additional chronic conditions (Additional Chronic Disease List). All such conditions meeting approval criteria may be authorised as per Scheme rules. Benefit limits apply, please contact your customer care centre for more assistance on your specific benefits.

Chronic Condition Application & Formulary:

The chronic medicine benefit application may be submitted to the PBM team by email [email protected] or via fax 086 680 8855.

• Application Completion- The chronic application form must be completed by the authorised treating Doctor.

• Application Submission- The completed application needs to be submitted to the PBM team when you wish to apply for consideration of cover for a new chronic condition, OR changes in chronic medicine for a condition previously approved.
  • Please ensure that the submission is done, as no medicine can be reviewed for chronic authorisation without submitting the completed application.

• Chronic Medication Formulary- The medicine listed for the specified conditions on the Chronic Medication Formulary is subject to Scheme entry and protocol approval criteria during the review of chronic conditions and related medicine applications.
  • Kindly take note of the specific criteria and requirements applied to certain conditions listed on the applicable Chronic Medication Formulary.
    • Should requirements be listed, please ensure, where possible, that the relevant requirements and applicable documentation (for example pathology/clinical reports) is submitted in addition to the completed application form.
  • Please be advised, in addition to the condition entry criteria, certain medicine listed on the formulary is subject to further, additional clinical criteria, upon review against Scheme protocols.
    • This may be indicated by the Additional Clinical Criteria column of the formulary.

Chronic Condition Review and Authorisation:

Chronic medicine is authorised individually with each case reviewed on its own clinical merit, in accordance with Scheme rules, managed healthcare principles and evidence based medicine.

The Scheme applies entry & approval criteria as well as Treatment Protocols to the review of chronic conditions and related medicine applications.

• Review- Each application is reviewed individually on its own clinical merit, with reference to the Scheme’s Chronic Condition List, applied entry & approval criteria, as well as Treatment Protocols.

• Authorisation- The PBM Team may authorise an amount for all approved chronic medicine which should be reflected on your chronic authorisation letter.

• Authorisation Amount- All approved chronic medicine, may be paid up to the maximum of the Chronic Drug Amount (CDA).
  • The approved amount (CDA) is determined based on the treatment protocols for all levels of treatment for each condition. The CDA is the maximum rand value (excluding dispensing fees) that may be approved for the authorised medicine.
  • Should the cost of the approved medicine be greater than the CDA, the member will be liable for the difference in price between the CDA and the cost of the claimed medicine.
  • The CDA is subject to market related price changes.

• Please refer to your Scheme’s Benefit Guide to confirm your annual benefits.

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